title: Fractional flow reserve-guided coronary bypass surgery: should surgeons use it?
abstract: OBJECTIVE
  Physiology-based evaluation in stable ischemic heart disease is transforming percutaneous cardiovascular intervention (PCI). Fractional flow reserve (FFR)-guided PCI is associated with more appropriate and beneficial outcomes at lower costs. The surgical community can no longer ignore this development. We review evidence for the rationale, practicality and appropriateness of FFR-guided coronary artery bypass grafting (CABG), as compared with the current conventional, anatomy-based strategy for surgical revascularization.
  
  
  RESULTS
  Physiologic evaluation links the nature (anatomic or functional) of coronary stenoses to the perfused myocardium supplied by the target vessel and challenges the use of anatomy as the sole criterion for revascularization intervention. In CABG, a functional perfusion deficit/ischemia identifies myocardial territories that would physiologically benefit from revascularization by grafting beyond the functional stenosis. Conversely, deliberately not grafting beyond an anatomic stenosis would dramatically change the procedure of CABG. Recent studies of functionally guided revascularization (PCI or CABG) support this approach, while recent trials of PCI vs. CABG demonstrated a late survival advantage with anatomy-based CABG. Finally, new intraoperative imaging technologies are elucidating the physiologic consequences of surgical revascularization in real time, yielding insights into resolving this dilemma.
  
  
  CONCLUSIONS
  Physiologic-based revascularization is challenging our thinking about the historic strategy for CABG. Understanding better the physiologic consequences of revascularization will drive the evolution of CABG in the future.
authors.affiliation: Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine at ECU, Greenville, North Carolina, USA.
authors.forename: T Bruce
authors.initials: TB
authors.lastname: Ferguson
authors.forename: C
authors.initials: C
authors.lastname: Chen
authors.forename: Ashesh N
authors.initials: AN
authors.lastname: Buch
mesh_terms: D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000379:methods*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D053805:Fractional Flow Reserve, Myocardial / Q000502:physiology*; D006801:Humans; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D018579:Patient Selection; D016896:Treatment Outcome